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Informing policy and practice to improve quality of care for malaria in pregnancy in Uganda

LEARNING BRIEF

Key messages:

Adopting a strategic approach to research uptake increases the likelihood of research results being taken up by policy-makers and practitioners.

Embedding research within Ministry of Health structures and frequent engagement with stakeholders are key elements of this approach.

Planning and budgeting for research uptake activities and continuing engagement with stakeholders beyond completion of the research are important to research uptake success.

Background

Research uptake: Public health research is crucial in generating evidence of what works in different contexts. In order for research to have an impact, it must be understood by policymakers and practitioners and used to influence their decision-making.

Research uptake refers to the activities that facilitate the use of research to inform policy and practice. It comprises advocacy and communications elements and involves engaging with stakeholders throughout the research process to ensure that the research is relevant to the needs and priorities in the country where the research is being undertaken.[1]

This brief describes the activities that supported research uptake for an operational research study which explored the barriers to achieving high coverage of intermittent preventive treatment for malaria in pregnancy (IPTp) in Uganda. The lessons learnt from implementing these activities can be useful for researchers who wish to increase the likelihood of their findings being taken up by policymakers and practitioners.

Intermittent preventive treatment for malaria in pregnancy: Intermittent preventive treatment for malaria in pregnancy (IPTp) is a vital component of malaria in pregnancy prevention and control strategies. It entails the administration of a curative dose of an antimalarial drug to all pregnant women, regardless of whether they are infected with malaria. It is typically delivered to pregnant women as part of routine antenatal care (ANC).[2] However, while coverage of ANC is high in most African countries, coverage of IPTp has remained comparatively low, suggesting that opportunities for the provision of IPTp during ANC are being missed. In Uganda, over 90 percent of women attend ANC at least twice, but only 45 percent of women receive at least two doses of IPTp.[3]

Study on barriers to IPTp uptake in Uganda: In 2013-14, Malaria Consortium conducted formative research exploring the barriers to IPTp uptake in Uganda. The study concluded that many of the missed opportunities for the provision of IPTp are due to inadequate health worker knowledge of the IPTp provision guidelines and poor service delivery practices.[4,5] To address this, Malaria Consortium implemented and evaluated a mobile health (mHealth) pilot intervention in 2014-15. The intervention involved conventional classroom training on malaria in pregnancy and complementing it with sending educational text messages to health workers to reinforce learning from the training. This approach was found to be feasible and well received by health workers. Text messaging also resulted in increased IPTp uptake compared with classroom training only.[6]

Informing policy and practice

The embedded approach: In order to increase the potential for change in policy and practice with regard to IPTp provision, this study adopted a strategic approach to research uptake, which involved engaging with relevant stakeholders throughout the duration of the study. This was informed by the principles of the ‘embedded approach’, which is based on the assumption that operational research is best prioritised, designed, conducted and replicated when it is embedded within Ministry of Health structures.[7]

Activities to support research uptake

Research uptake strategy: At the start of the research, the study team conducted a workshop to identify relevant national and international stakeholders. The Alignment, Interest and Influence Matrix (AIIM) tool [8] was used to facilitate an analysis of relevant stakeholders’ interest in IPTp and whether their objectives were aligned with the research objective of increasing IPTp coverage. Based on this analysis, a research uptake strategy outlined how key stakeholders would be informed and involved throughout the study. Key messages, budgeted activities and measurable targets were set for each stakeholder. The research team regularly reported on progress against the strategy, which was reviewed and updated throughout the study.

Consulting stakeholders in study design, implementation and interpretation of results: The formative research was designed in consultation with the Uganda National Malaria Control Programme (NMCP) and the findings were presented at a stakeholder meeting hosted by the NMCP. Based on the formative research results, stakeholders tasked Malaria Consortium with developing a pilot intervention to improve health worker performance with regard to IPTp. A steering committee comprising members from the NMCP, Reproductive Health Division, Resource Centre and District Health Officers from the study districts was formed to guide the development and implementation of the intervention. The results from the evaluation of the pilot intervention were discussed at a stakeholder meeting organised by the NMCP.

The study team also presented progress and findings at suitable national and international stakeholder meetings, such as those hosted by Roll Back Malaria, the President’s Malaria Initiative or the UK All-party Parliamentary Group on Malaria and Neglected Tropical Diseases. Briefing materials tailored to non-academic audiences such as project and research briefs were shared during these meetings. As changes in policy and practice occur over time, engagement with stakeholders and monitoring research uptake successes continued after completion of the research.

Research uptake successes

The research uptake activities successfully influenced policy and decision makers to use the study results to increase IPTp coverage in Uganda:

The Ministry of Health pledged to reconsider how drugs are supplied to private sector health facilities, in response to the finding that current supply mechanisms lead to drug stock-outs in private sector facilities.

The formative research concluded that the national guidelines governing IPTp provision in Uganda were not in line with the most recent World Health Organization (WHO) policy recommendation. These outline the number of doses required and ideal timing making it easier for health workers to apply the guidelines in their day-to-day work. In several meetings where the research was presented, stakeholders emphasised that the WHO recommendation should be adopted as a matter of urgency in order to strengthen women’s protection from malaria in pregnancy. Uganda adopted the WHO recommendation in 2016.

The Ministry of Health committed to adopting the text messaging approach pilot tested in this study in its national malaria in pregnancy training strategy. This means that health workers across the country will receive educational messages on their mobile phone, which will remind them of the importance of IPTp to pregnant women and how to provide IPTp according to provision guidelines.

Challenges

The main challenges relating to research uptake on this study included the following:

There were reservations among some stakeholders on the use of a qualitative design in the formative research and a pilot study design to evaluate the mHealth intervention. These concerns were addressed by explaining to stakeholders the suitability of these approaches and by modifying the research design – for example, by including additional interviews in the formative research and a control group in the pilot study.

The timescales of the study had to be adjusted in order to align the pilot study with ongoing discussions within the Ministry of Health about adopting the most recent WHO policy recommendation for IPTp. This involved deferring the pilot intervention by several months in order to give the NMCP time to develop an updated malaria in pregnancy training manual. The manual was used in the classroom training provided as part of this study.

While the NMCP was initially seen as the key stakeholder within the Ministry of Health, it became increasingly clear that IPTp was a cross-cutting issue that required close collaboration with the Reproductive Health Division and Resource Centre. Building up cross-departmental support required substantive effort, for example through close involvement in the Ministry of Health’s malaria in pregnancy technical working group.

Conclusion

The study on barriers to IPTp uptake in Uganda provides a good example of how a small-scale study can inform policy and practice by providing robust and relevant research evidence to policy makers. Key to the research uptake successes of this study were its strategic approach to research uptake and the close engagement with relevant stakeholders, in particular those from the Ministry of Health during all stages of the research project. Setting aside a budget for research uptake activities and continuing engagement with stakeholders beyond completion of the research were important factors of research uptake success.

World Health Organization. (2014) WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). Geneva, Switzerland. Link

Acknowledgements: The study was conducted through COMDIS-HSD, a Research Programme Consortium funded by the UK government. It also received Programme Partnership Arrangement funding from the UK government. However, the views expressed do not necessarily reflect the UK government’s official policies.

Published by Malaria Consortium / March 2017 This publication may be reproduced in whole or in part for non-profit or educational purposes, provided that acknowledgement is made to Malaria Consortium. Please send a copy or link of the reprinted material to Malaria Consortium. No images from this publication may be used without prior permission from Malaria Consortium.